Mr. Sehgal spoke often to his family about his desire to donate organs and tissues after death. When he expired in a hospital recently, following a prolonged illness, the family approached the treating team for cornea donation. However, they were disappointed to learn that cornea retrieval was not possible, as eye bank services had been suspended because of COVID-19. The pandemic has led to cancellation of elective surgeries and non-essential procedures. The reasons for this are many. In the midst of an advisory on social distancing, it is considered prudent to seek video consultations and try to avoid travel to a hospital. Also, even though hospital resources may not be stretched in the early phase of the pandemic, it is wise to conserve critical resources and limit exposure of hospital staff to the virus.

Is cornea donation and transplantation an elective surgery?

We carry out 25000 cornea transplants annually in India, which is less than a quarter of the actual requirement. Assuming that the COVID-19 epidemic leads to restrictions for one month, more than 2000 blind individuals stand to lose the chance of regaining vision. If you ask those awaiting cornea transplants eagerly, they will tell you in no uncertain terms that for them, it is an essential service and not an elective surgery!

What about organ transplantation?

Patients with end stage disease due to failure of kidney, liver, heart and lungs are following the pandemic with increasing anxiety. While the kidney failure patients can continue dialysis, albeit at slightly higher risk of contracting COVID-19, there is no such luxury for patients with a failing liver, heart or lung. The impact of delaying a transplant could be catastrophic. Let us take a closer look :-

Deaths from all causes will continue to happen. Even as the COVID-19 pandemic rages, mortality from all other diseases will continue. While donation of tissues like cornea, skin, bones etc. is possible within 6 to 8 hours of death, organ donation is usually possible only when patients with catastrophic brain injury develop brain death while on ventilator and the heart is till beating. Not approaching families of the deceased for donation will worsen the already critically low pool of organs and tissues. Counseling of families for tissue and organ donation is usually carried out by doctors, transplant coordinators or nurses, all of whom continue to work in hospitals. In the absence of public transport, hospitals are going out of their way to help their staff with conveyance to work and back. Transportation of four members of the committee to certify brain death should also not be a problem.

Should organ transplantation and eye banking be regarded as an essential service?

Urgent life saving organ transplants are continuing throughout the world but eye banking services have been affected in several countries. In the US however, eye banks are recognized by the Federal Emergency Management Agency under Emergency Support Function #8 as critical public health and medical services. Eye banks issue a letter to recovery technicians that permits them to travel on restricted roads or to enter hospitals and morgues. There should be no problem in providing a similar letter to cornea retrieval teams in our country. In any case, most eye bank teams in India ply in ambulances that have the privilege of unhindered movement.

Is testing for COVID-19 mandatory before organ or tissue retrieval?

In deceased organ donation after brain death, it is mandatory to carry out testing for COVID-1 in the prospective donor. Only one test is recommended as time is at a premium. Uncontrolled Donation after Circulatory Death (DCD) is not possible during the pandemic as the process does not allow the luxury of time for testing. Living donors are eligible to donate only if they have not travelled outside the country in the previous 21 days and have twice tested negative for COVID-19, the last within 24 hours of the surgery. As far as cornea retrieval is concerned, Eye Bank Association of America recommends testing for COVID-19 prior to cornea retrieval in the following circumstances:-

Tested postive for COVID-19 within past two monthsAcute respiratory illness with fever, dry cough or shortness of breath with no other known etiology within last 28 days (twice the maximum reported incubation period of 14 days)Close contact with a person who has confirmed COVID-19 infection or with a Person Under Investigation (PUI) with in last 28 daysTravel to or transit through a country indentified as level 2 or 3 travel risk within last 28 daysARDS, pneumonia or CT scan showing ground glass opacities regardless of etiology within last 28 daysHowever, in our context, the above may be considered exclusion criteria for cornea retrieval without testing for COVID-19. Nevertheless, blood samples from corneal donors should be stored so that subsequent testing is possible, if required.

Is there increased risk of transmission of COVID-19 to retrieval staff?

There is no increased risk to the organ transplant teams as a negative test for COVID-19 on the donor is mandatory before for any organ retrieval.

As far as cornea retrieval in the hospitals and homes is concerned, there may be an element of fear in the staff from eye banks. Do they need any special protection? As per current policy, the staff in ICUs that house patients with proven COVID-19 are entitled to the Hazmat suits or full PPE. Those from specialties like anesthesia, ENT, pulmonology, ophthalmology, GI endoscopy and dentistry, who are directly exposed to aerosols, are required to wear PPE including the N-95 mask and eye protection. Most other doctors, nurses and paramedical staff continue to perform their duty with strict hand hygiene precautions and a triple-layer surgical mask. Cornea retrieval teams have no extra risk as compared to any other health professionals even though there is some evidence to suggest the presence of the virus in tears. The Royal College of Pathologists (UK) recommends use of gowns, gloves, face masks and eye protection for care of deceased during the COVID-19 pandemic.

Are tissue and organ transplant recipients at higher risk for COVID-19?

According to the Global Alliance for Eye Banking (GAEB), there is no current evidence that corona viruses can be transmitted by blood transfusions or tissue transplants. There is no report till date of transmission of the virus with organ transplant but it has been shown that SARS- CoV-2 has a high tropism for the kidney, where it has been shown to replicate in almost 30% of patients. Cornea transplant recipients do not require blood group matching or oral medication to reduce their immunity to prevent rejection. So there is no increased risk.

However, organ transplant recipients require high dose immunosuppression during the first 3 months and a lower dose for a lifetime. It is felt that the inoculum size of COVID-19 required to infect a transplant patient may be lower and progression to life threatening pneumonia more likely. Experience with COVID-19 infection in transplanted patients on long-term immunosuppression does not suggest worst outcomes or requirement for reduction in dose.

In fact, some experts feel that impaired cellular immune function may lead to better outcomes due to inability to mount a significant cytokine storm. It is recommended by the Indian Society of Organ Transplant (ISOT) that living donor kidney transplantation may best be deferred during this period. However, living donor liver transplant may be considered in patients with acute life threatening forms of liver failure. Transplantation of heart, lungs, liver and kidneys following deceased donation may be allowed to continue depending upon the stage of the pandemic and whether the health services are overwhelmed with COVID-19 patients.

Will organs and tissues be effectively utilized?

It is possible that there may be reluctance on the part of prospective recipients to step out of their homes and accept organs and tissues. Given the acute shortage of organs and tissues in the country, though, with proper counseling most of them would consider receiving a call on availability of a suitable donor an Act of God. Even though green corridors will not be required to transport organs, as the roads are empty, inter-city sharing of organs by commercial aircrafts will be affected. The eye banks too, with their current embargo, need also to consider ways to provide emergency tissue in situations like perforations and penetrating injuries to the cornea.

Any recommendation must take into consideration the balance between the stage of COVID-19 pandemic, the risks of suspending or delaying transplantation and the risk posed to potential recipients and the medical personnel. Dr Li Wenliang, considered one of the prime whistleblowers of COVID-19, was an Ophthalmologist in Wuhan. He succumbed to the virus after contracting the infection from a patient with glaucoma. Perhaps, we owe it to him to continue eye banking and transplant services, but only for those who need it most.

DISCLAIMER: The views expressed are solely of the author and ETHealthworld.com does not necessarily subscribe to it. ETHealthworld.com shall not be responsible for any damage caused to any person/organisation directly or indirectly.

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